Case-based MCQs — Acute Rheumatic Fever

1. A 9-year-old boy presents 3 weeks after an untreated sore throat with migratory, hot,
swollen knees and ankles. He has fever and an audible new holosystolic murmur at the
apex. Which diagnostic set is most appropriate to confirm ARF?
A. Any single major manifestation is enough.
B. Two major criteria, or one major + two minor, plus evidence of recent GAS infection.
C. Elevated ASO titer alone is diagnostic.
D. Presence of fever and arthralgia only.
2. A 7-year-old girl with abrupt onset involuntary, irregular movements of the face and
hands 8 months after sore throat, with normal ESR/CRP now. What is the best diagnostic
approach?
A. Exclude other causes — chorea alone can be ARF even without other criteria.
B. Require two major criteria.
C. Wait for ESR elevation to decide.
D. Diagnose only if ASO is positive.
3. A 10-year-old with migratory polyarthritis and mild mitral regurgitation on echo (no
cardiomegaly). Which anti-inflammatory regimen is recommended for arthritis-only or
mild carditis?
A. IV methylprednisolone only.
B. High-dose aspirin (salicylates) per pediatric dosing.
C. No anti-inflammatory therapy — only antibiotics.
D. Lifelong NSAIDs.
4. A child with ARF and congestive heart failure from moderate–severe carditis should
receive:
A. Only aspirin, regardless of heart failure.
B. Corticosteroids plus standard heart failure therapy (digoxin/diuretics) as needed.
C. No anti-inflammatory treatment because it worsens HF.
D. Immediate valve replacement.
5. Which organism and antecedent infection are classically linked to ARF?
A. Staphylococcus aureus — skin infection.
B. Group A β-hemolytic streptococcus — pharyngitis.
C. Haemophilus influenzae — otitis media.
D. Mycoplasma pneumoniae — atypical pneumonia.
6. A 6-year-old with erythematous non-pruritic serpiginous rash on trunk that worsens with
heat and a history of sore throat 3 weeks earlier — the rash most likely is:
A. Erythema nodosum.
B. Erythema marginatum — a major Jones criterion.
C. Urticaria.
D. Scarlet fever rash.
7. Which of the following is NOT a major Jones criterion?
A. Migratory polyarthritis.
B. Subcutaneous nodules.
C. Prolonged PR interval on ECG.
D. Sydenham’s chorea.
8. A child diagnosed with ARF should receive secondary prophylaxis to prevent
recurrences. The standard intramuscular benzathine penicillin dosing (approx) is:
A. 600,000 IU IM every 3–4 weeks if <27 kg; 1.2 million IU if ≥27 kg.
B. 2.4 million IU IM daily.
C. 600,000 IU IV once then stop.
D. Erythromycin only for all patients.
9. A 11-year-old with suspected ARF has an ASO titer >200 Todd units. Which is true
about ASO titers?
A. ASO peaks at ~3 weeks after infection and may normalize by 6 weeks.
B. ASO is specific for current carditis severity.
C. A negative ASO excludes prior GAS infection always.
D. ASO is used to monitor response to aspirin.
10. A child presents with fever, migratory joint pain and a new mitral regurgitation murmur.
ESR and CRP are markedly elevated. According to the modified Jones criteria, he meets:
A. Insufficient criteria — need two major features.
B. One major (carditis) and two minor (fever + high acute phase reactants) — sufficient
with evidence of GAS.
C. Only minor criteria.
D. Diagnosis requires biopsy.
11. A 12-year-old with mild ARF arthritis is started on high-dose aspirin. How long is aspirin
typically continued?
A. 3–5 days at anti-inflammatory dosing then lower dosing for ~4 weeks until
symptoms/ESR normalize.
B. Lifetime aspirin.
C. Single dose only.
D. Aspirin is contraindicated in ARF.
12. Which of the following clinical features is most likely to leave permanent sequelae?
A. Migratory arthritis.
B. Sydenham chorea.
C. Carditis (valvular damage).
D. Erythema marginatum.
13. A child with suspected ARF has a prolonged PR interval on ECG but no audible murmur.
Which statement is true?
A. A prolonged PR interval is a minor manifestation and cannot be used if carditis is
counted as a major criterion.
B. A prolonged PR interval is a major criterion.
C. PR prolongation excludes ARF.
D. PR interval is unrelated to ARF diagnosis.
14. A 9-year-old previously diagnosed with rheumatic heart disease presents with fever and
arthralgia. To diagnose a recurrence of ARF in a patient with prior RHD, which is
sufficient?
A. One major or two minor plus evidence of preceding GAS infection.
B. Two major only with no serology.
C. Chorea alone cannot be recurrence.
D. Recurrence cannot be diagnosed — only new cases apply.
 15. A child with ARF develops firm painless subcutaneous nodules over extensor surfaces.
These nodules indicate:
A. They are common and harmless, lasting years.
B. They’re rare but associated with significant rheumatic heart disease and strong
seropositivity.
C. Pathognomonic of juvenile idiopathic arthritis.
D. Immediate indication for valve surgery.
16. Which is the best primary prevention strategy to reduce risk of ARF after GAS
pharyngitis?
A. Timely diagnosis and antibiotic treatment of GAS pharyngitis (penicillin).
B. Vaccination against Staphylococcus.
C. Routine IVIG for all sore throats.
D. Avoiding all antipyretics.
17. A child with suspected ARF has severe carditis with cardiomegaly and CHF. Which anti-
inflammatory is preferred in severe carditis?
A. Continue aspirin only.
B. Systemic corticosteroids (e.g., prednisone or IV methylprednisolone) plus supportive
HF therapy.
C. NSAIDs other than aspirin.
D. No anti-inflammatory — only antibiotics.
18. Which lab or investigation is most specific for recent GAS infection supporting ARF
diagnosis?
A. Elevated ESR alone.
B. Positive throat culture or rapid streptococcal antigen test OR rising streptococcal
antibody titer (ASO/anti-DNase B).
C. Leukocytosis alone.
D. Chest X-ray showing cardiomegaly.
19. A 8-year-old with ARF is allergic to penicillin. Recommended alternative for eradication
of GAS is:
A. Erythromycin or azithromycin oral for 10 days.
B. Vancomycin PO for 3 days.
C. No antibiotics needed if arthritis present.
D. IM benzathine penicillin regardless of allergy.
20. Long-term prognosis after an initial ARF attack is most strongly predicted by:
A. Patient’s gender only.
B. Presence and severity of initial carditis — more severe initial cardiac involvement →
greater risk of residual heart disease.
C. Whether erythema marginatum was present.
D. Time of year when infection occurred.

Answers & brief explanations

Source for most answers: Acute Rheumatic Fever slides (Acute Rheumatic Fever by
[Link]).
Acute Rheumatic Fever by Mig

Acute Rheumatic Fever by Mig

Acute Rheumatic Fever by Mig

1. B. Modified Jones: 2 major OR 1 major + 2 minor plus evidence of recent GAS

infection.

Acute Rheumatic Fever by Mig

2. A. Sydenham’s chorea may be the sole manifestation — diagnosis can be made with
chorea alone after excluding other causes. Note chorea can present months after infection.

Acute Rheumatic Fever by Mig

3. B. Migratory polyarthritis or mild carditis is treated with high-dose salicylates (aspirin)

per pediatric dosing (then tapered).

Acute Rheumatic Fever by Mig

4. B. Severe carditis with heart failure often requires corticosteroids plus standard HF
therapy (diuretics, ACE inhibitors, digoxin as indicated).

Acute Rheumatic Fever by Mig

5. B. ARF follows Group A β-hemolytic streptococcal pharyngitis (GAS). Skin

streptococcal infections are not associated.

Acute Rheumatic Fever by Mig

6. B. Erythema marginatum is a characteristic (though uncommon) rash of ARF; worsens

with heat and is non-pruritic.

Acute Rheumatic Fever by Mig

7. C. Prolonged PR interval is a minor criterion; the five majors are carditis, migratory
polyarthritis, chorea, erythema marginatum, subcutaneous nodules.

Acute Rheumatic Fever by Mig

8. A. Secondary prophylaxis: benzathine penicillin IM every 3–4 weeks — dosing approx

600,000 IU <27 kg; 1.2 million IU ≥27 kg. Alternatives for penicillin allergy include
erythromycin.

Acute Rheumatic Fever by Mig

9. A. ASO titers typically peak ~3 weeks after infection and may fall toward normal by ~6
weeks; a single ASO has limits.

Acute Rheumatic Fever by Mig

10. B. Carditis = major. Fever + raised acute-phase reactants = two minor. With evidence of
recent GAS (throat culture/ASO), this meets Jones.

Acute Rheumatic Fever by Mig

11. A. Pediatric aspirin regimen: high anti-inflammatory dosing for several days then
reduced/continued until symptoms and acute-phase reactants normalize (typical durations
per slides).

Acute Rheumatic Fever by Mig

12. C. Carditis (valvular damage) is the manifestation that commonly leaves permanent
sequelae (rheumatic heart disease). Arthritis and chorea usually resolve.

Acute Rheumatic Fever by Mig

13. A. Prolonged PR is a minor criterion; guideline notes you cannot count a minor PR
interval when carditis is used as the major manifestation (i.e., don’t double-count).

Acute Rheumatic Fever by Mig

14. A. In a patient with existing RHD, 1 major or 2 minor + evidence of GAS suffices to
diagnose recurrence (modified rules).

Acute Rheumatic Fever by Mig

15. B. Subcutaneous nodules are rare but when present are associated with more significant
rheumatic heart disease and strong seropositivity.

Acute Rheumatic Fever by Mig

16. A. Timely antibiotic treatment of GAS pharyngitis (penicillin) is the key primary
prevention measure.

Acute Rheumatic Fever by Mig

17. B. Severe carditis (with cardiomegaly/CHF) is typically managed with systemic steroids
(often IV methylprednisolone) plus heart failure treatment.

Acute Rheumatic Fever by Mig

 18. B. Supportive evidence of recent GAS infection includes positive throat culture/rapid
antigen or rising streptococcal antibody titers (ASO/anti-DNase B); ESR/CRP are
supportive but nonspecific.

Acute Rheumatic Fever by Mig

19. A. For penicillin allergy, erythromycin or azithromycin for 10 days are acceptable
alternatives for eradication/prophylaxis.

Acute Rheumatic Fever by Mig

20. B. The presence and severity of initial carditis is the strongest predictor of long-term
residual heart disease (prognosis worse with more severe initial cardiac involvement).

Acute Rheumatic Fever by Mig

20 Case-Based MCQs — Cardiomyopathy in Children

1. A 3-month-old infant presents with tachypnea, poor feeding, recurrent pneumonia, and
cardiomegaly on CXR. Echo shows a dilated left ventricle with reduced systolic function. What is the
most likely diagnosis?

A. Restrictive cardiomyopathy
B. Dilated cardiomyopathy
C. Hypertrophic cardiomyopathy
D. Arrhythmogenic RV cardiomyopathy

2. A 14-year-old athlete collapses during basketball practice. ECG shows LVH, and echo reveals marked
asymmetric septal hypertrophy without dilation. What type of cardiomyopathy is most likely?

A. Dilated cardiomyopathy
B. Hypertrophic cardiomyopathy
C. Restrictive cardiomyopathy
D. ARVC

3. Which pediatric cardiomyopathy is most commonly associated with systolic dysfunction and heart
failure?

A. Hypertrophic
B. Dilated
C. Restrictive
D. ARVC

4. A 9-year-old boy has chronic cough and wheezing diagnosed repeatedly as “asthma.” He now has
exertional fatigue and abdominal pain. Echo shows a dilated LV with poor contractility. What
condition was likely missed?

A. Dilated cardiomyopathy misdiagnosed as asthma

B. Restrictive cardiomyopathy
C. Hypertrophic cardiomyopathy
D. ARVC

5. A neonate presents with severe heart failure. Echo shows restrictive filling with bi-atrial
enlargement. Ventricular size is normal. What cardiomyopathy best fits?

A. DCM
B. HCM
C. RCM
D. ARVC

6. A 12-year-old boy has syncope during exercise. ECG shows deep Q waves and echo showing
thickened septum obstructing LV outflow. What complication is he most at risk for?

A. Pulmonary embolism
B. Sudden cardiac death
C. Infective endocarditis
D. Chronic arrhythmogenic stroke

7. A 10-year-old on chemotherapy for leukemia develops fatigue, dyspnea, and an enlarged LV with
poor EF. Which category of DCM causes is this?

A. Idiopathic
B. Neuromuscular
C. Metabolic
D. Drug-induced (anthracycline toxicity)
8. A 6-year-old with HCM shows thickened ventricular septum without dilation. What is the hallmark
definition of HCM?

A. Dilated ventricle with poor contractility

B. Rigid ventricles with impaired filling
C. Hypertrophied nondilated ventricle without another cause
D. RV replaced with fibro-fatty tissue

9. A teenager with palpitations has echo findings of a “spongy” myocardium with deep trabeculations
in the LV. Diagnosis?

A. ARVC
B. LV non-compaction cardiomyopathy
C. DCM
D. HCM

10. An infant with DCM shows poor feeding, diaphoresis, and recurrent respiratory infections. What is
the most common presenting feature in infants?

A. Chest pain
B. Syncope
C. Respiratory distress and feeding difficulty
D. Leg edema only

11. Which cardiomyopathy is associated with fibro-fatty replacement of RV myocardium and

ventricular arrhythmias?

A. HCM
B. RCM
C. ARVC
D. DCM

12. A 15-year-old boy has a history of fainting during sports. Family history reveals sudden deaths in
two uncles. Echo shows asymmetric septal hypertrophy. What is the inheritance pattern in most HCM
cases?

A. Autosomal recessive
B. Autosomal dominant
C. X-linked
D. Mitochondrial

13. A child with DCM develops heart failure. Which medication is part of standard HF management?

A. Aspirin
B. ACE inhibitors + diuretics ± digoxin
C. Anticoagulation alone
D. Calcium channel blockers only

14. Which of the following is the most common type of cardiomyopathy in children?

A. HCM
B. RCM
C. DCM
D. ARVC

15. A newborn has tachypnea and hepatomegaly. Echo shows DCM. Which congenital infection or
condition is strongly associated with neonatal DCM?

A. CMV myocarditis
B. Hepatitis A
C. Varicella
D. Adenovirus only

16. A 4-year-old with DCM presents with tachycardia and hepatomegaly. His echo shows EF 25%.
Which screening should be considered?

A. Screen parents and siblings for familial DCM

B. Screen for diabetes only
C. No screening needed
D. Drug toxicity testing only

17. Which best describes restrictive cardiomyopathy physiology?

A. Decreased afterload with high stroke volume

B. Enlarged RV causing outflow obstruction
C. Stiff ventricles with impaired filling and enlarged atria
D. Dilated LV with reduced EF

18. Which cardiomyopathy carries the highest association with sudden cardiac death in adolescents?

A. DCM
B. HCM
C. RCM
D. ARVC

19. A 12-year-old boy with HCM has no symptoms. What is the general activity recommendation?

A. No restrictions needed
B. Avoid all sports and physical activity
C. Avoid competitive sports due to SCD risk
D. Encourage intense exercise to strengthen LV

20. A child with DCM has persistent severe EF <20% despite maximal therapy. Next step?

A. Observe
B. Heart transplantation referral
C. Treat with steroids
D. Device closure

ANSWER KEY + EXPLANATIONS

Based on: “Cardiomyopathies in Children by Mig”

Cardiomyopathies in children by…

1. B — Dilated cardiomyopathy
DCM is most common in infants; presents as respiratory symptoms and feeding difficulty.

2. B — HCM
Asymmetric septal hypertrophy in athletes → classic HCM.

3. B — DCM
Most common cause of systolic HF in children.
 4. A — DCM misdiagnosed as asthma
Cough/wheeze during activity is classic DCM mimic.

Cardiomyopathies in children by…

5. C — Restrictive cardiomyopathy
Stiff ventricles, normal size, bi-atrial enlargement.

6. B — Sudden cardiac death

HCM is a major cause of exertional SCD in adolescents.

7. D — Drug-induced DCM
Anthracyclines (chemotherapy) are classic toxic causes.

Cardiomyopathies in children by…

8. C — Hypertrophied nondilated ventricle

Hallmark definition; not due to hypertension or AS.

Cardiomyopathies in children by…

9. B — LV non-compaction (LVNC)
Deep trabeculations, two-layer myocardium.

Cardiomyopathies in children by…

10. C — Respiratory distress/feeding difficulty

Most common in infants, often mistaken for pneumonia.

Cardiomyopathies in children by…

11. C — ARVC
RV replaced with fibrofatty tissue → arrhythmias.

Cardiomyopathies in children by…

12. B — Autosomal dominant

75% of HCM are familial AD.

Cardiomyopathies in children by…

13. B — ACE inhibitors, diuretics ± digoxin

Standard HF regimen for DCM.

14. C — DCM
Most common overall (51%).

Cardiomyopathies in children by…

 15. A — CMV or viral myocarditis
Viral myocarditis is a major cause of DCM.

Cardiomyopathies in children by…

16. A — Screen family

Genetic/familial causes present in many DCM cases.

Cardiomyopathies in children by…

17. C — Stiff ventricles, enlarged atria

Classic restrictive physiology.

18. B — HCM
Highest risk of SCD in young athletes.

19. C — Avoid competitive sports

Due to arrhythmia/SCD risk.

20. B — Heart transplantation

Severe refractory DCM → transplant is indicated.

20 Case-Based MCQs — Congenital Heart

Disease (CHD)

1. A 2-month-old infant has poor feeding, tachypnea, and a harsh holosystolic

murmur at the left lower sternal border. CXR shows cardiomegaly and increased
pulmonary vascular markings. What is the most likely diagnosis?

A. Tetralogy of Fallot
B. VSD
C. ASD
D. Pulmonary stenosis

2. A 4-year-old with a widely split, fixed S2 and systolic ejection murmur at the
pulmonary area most likely has:

A. ASD
B. PDA
C. TOF
D. Coarctation of the aorta

3. A newborn with differential cyanosis (pink upper body, cyanotic lower limbs)
likely has:

A. PDA with pulmonary hypertension (Eisenmenger physiology)

B. Preductal coarctation of aorta
C. Postductal coarctation
D. ASD

4. A 2-day-old newborn becomes cyanotic and collapses when the ductus

arteriosus closes. Which defect is duct-dependent for systemic circulation?

A. Tetralogy of Fallot
B. ASD
C. Transposition of the great arteries (TGA)
D. VSD

5. A child has a continuous “machinery” murmur at the left infraclavicular area.

What CHD is this typical of?

A. ASD
B. PDA
C. TOF
D. AV canal defect

6. A 5-year-old with cyanotic spells that improve when squatting most likely has:

A. TAPVR
B. Tetralogy of Fallot
C. Coarctation of aorta
D. ASD
7. A newborn with bounding pulses, wide pulse pressure, and continuous
murmur likely has:

A. Coarctation
B. PDA
C. TOF
D. Pulmonary stenosis

8. An infant with failure to thrive has a systolic murmur and a single loud S2.
CXR shows "egg-on-a-string" heart. Likely diagnosis?

A. TGA
B. TOF
C. VSD
D. Truncus arteriosus

9. A 3-year-old has a harsh systolic ejection murmur at left upper sternal border
with palpable thrill. What lesion is this typical of?

A. Pulmonary stenosis
B. ASD
C. Coarctation
D. PDA

10. A newborn with shock and severe acidosis at day 2 of life. Femoral pulses are
weak. Which is the next immediate management step?

A. Start ACE inhibitors

B. Administer prostaglandin E1 infusion
C. Mechanical ventilation only
D. Surgical correction immediately

11. A 10-year-old with Turner syndrome is most at risk of which CHD?

A. ASD
B. Coarctation of the aorta
C. TGA
D. Ebstein anomaly

12. A child has a harsh systolic murmur with cyanosis, decreased pulmonary
vascularity on CXR, and boot-shaped heart. Diagnosis?

A. TOF
B. TGA
C. Truncus arteriosus
D. PDA

13. A teenager has upper limb hypertension and diminished femoral pulses.
Murmur heard over the back. Diagnosis?

A. ASD
B. PDA
C. Coarctation of aorta
D. Tricuspid atresia

14. A neonate has severe cyanosis not responding to oxygen. Echo shows
complete mixing with single arterial trunk. Diagnosis?

A. Truncus arteriosus
B. TOF
C. TGA
D. VSD

15. A child has recurrent respiratory infections and failure to thrive. Wide fixed
S2. Echo shows left-to-right shunt. Complication if untreated?

A. Pulmonary stenosis
B. Eisenmenger syndrome
C. Aortic stenosis
D. PDA closure
16. A child with Down syndrome presents with a loud S2 and holosystolic
murmur. What CHD is strongly associated?

A. ASD
B. AV canal defect (AVSD)
C. Coarctation
D. Pulmonary atresia

17. A neonate with cyanosis has minimal murmur, severe hypoxia, and requires
mixing at atrial level to survive. Which lesion?

A. TGA
B. TOF
C. PDA
D. VSD

18. A 6-year-old with PDA is at increased risk for:

A. Brain abscess
B. Pulmonary hypertension/Eisenmenger syndrome
C. Severe aortic stenosis
D. Coarctation

19. A child with harsh systolic murmur, RVH on ECG, and decreased
pulmonary blood flow has:

A. VSD
B. TOF
C. ASD
D. PDA

20. A premature infant has PDA with heart failure. Which medication can close
PDA?

A. Indomethacin or ibuprofen
B. Prostaglandin E1
C. ACE inhibitors
D. Digoxin only

ANSWERS + EXPLANATIONS
1. B — VSD
Harsh holosystolic LLSB murmur, FTT, cardiomegaly = classic VSD.

2. A — ASD
Fixed split S2 = hallmark of ASD.

3. A — PDA with pulmonary hypertension (Eisenmenger)

Deoxygenated blood flows to descending aorta → lower body cyanosis.

4. C — TGA
TGA is duct-dependent for mixing/systemic output.

5. B — PDA
Continuous “machinery” murmur.

6. B — Tetralogy of Fallot
Tet spells relieved by squatting → increases SVR.

7. B — PDA
Bounding pulses + wide pulse pressure.

8. A — TGA
Egg-on-a-string heart (narrow mediastinum).

9. A — Pulmonary stenosis
Harsh systolic ejection murmur with thrill at LUSB.

10. B — Prostaglandin E1
Keeps PDA open in duct-dependent lesions (e.g., coarctation).

11. B — Coarctation
Turner syndrome strongly associated.

12. A — TOF
Boot-shaped heart + decreased pulmonary markings.

13. C — Coarctation
BP differential and absent femoral pulses.
14. A — Truncus arteriosus
Single great artery + mixing physiology.

15. B — Eisenmenger syndrome

Chronic L→R shunt → pulmonary HTN → reversal.

16. B — AV canal defect

Classic in Down syndrome.

17. A — TGA
Severe cyanosis + minimal murmur; requires atrial mixing.

18. B — Pulmonary hypertension/Eisenmenger

Significant PDA can lead to irreversible pulmonary vascular disease.

19. B — TOF
RVH, harsh systolic murmur, decreased pulmonary blood flow.

20. A — Indomethacin/ibuprofen
Closes PDA in preterm infants.

20 Case-Based MCQs — Childhood Cancers

1. A 4-year-old presents with pallor, fever, bone pain, and hepatosplenomegaly. CBC shows anemia,
thrombocytopenia, and blast cells. What is the most likely diagnosis?

A. Neuroblastoma
B. Acute lymphoblastic leukemia (ALL)
C. Wilms tumor
D. Retinoblastoma

2. The MOST common childhood cancer is:

A. Brain tumors
B. ALL
C. Hodgkin lymphoma
D. Wilms tumor

3. A 2-year-old with abdominal distention has a firm, smooth, unilateral mass that does not cross the
midline. His BP is elevated. Which cancer is likely?
A. Neuroblastoma
B. Wilms tumor
C. Hepatoblastoma
D. Burkitt lymphoma

4. A child with neuroblastoma develops periorbital ecchymosis (“raccoon eyes”) and bone pain. What
does this indicate?

A. Localized tumor only

B. Metastatic spread
C. Eye trauma
D. Vitamin deficiency

5. A toddler with leukocoria (white pupillary reflex) and strabismus likely has:

A. Cataracts
B. Retinoblastoma
C. Optic neuritis
D. Glaucoma

6. A 6-year-old presents with painless cervical lymphadenopathy, intermittent fever, weight loss, and
night sweats. Reed-Sternberg cells are seen. Diagnosis?

A. Non-Hodgkin lymphoma
B. Hodgkin lymphoma
C. Neuroblastoma
D. Osteosarcoma

7. A teenager presents with localized bone pain worse at night, swelling over the distal femur, and
“sunburst” periosteal reaction on X-ray. Diagnosis?

A. Osteosarcoma
B. Ewing sarcoma
C. Osteomyelitis
D. Langerhans cell histiocytosis
8. A 9-year-old boy presents with fever, weight loss, and a mediastinal mass. Biopsy shows sheets of
small blue cells. What is likely?

A. Ewing sarcoma
B. T-cell ALL
C. Hodgkin lymphoma
D. Wilms tumor

9. Which childhood tumor is associated with elevated catecholamine metabolites (VMA/HVA) in

urine?

A. Wilms tumor
B. Neuroblastoma
C. Hepatoblastoma
D. Medulloblastoma

10. A 3-year-old child with abdominal mass and hematuria is found to have WT1 deletion. This finding
is associated with:

A. Retinoblastoma
B. Wilms tumor
C. Neuroblastoma
D. Osteosarcoma

11. A 10-year-old with headaches, vomiting worse in the morning, and ataxia likely has a tumor in the:

A. Frontal lobe
B. Cerebellum
C. Temporal lobe
D. Optic nerve

12. A child with bone pain, fever, and lytic bone lesions on X-ray showing an “onion-skin” pattern
most likely has:

A. Osteosarcoma
B. Ewing sarcoma
C. Osteomyelitis
D. Rhabdomyosarcoma
13. A 5-year-old with rapid abdominal enlargement, diarrhea, and jaw mass is diagnosed with a
lymphoma strongly linked with EBV. Which type?

A. Hodgkin lymphoma
B. Burkitt lymphoma
C. T-cell ALL
D. Rhabdomyosarcoma

14. A neonate with abdominal mass and elevated AFP is most likely to have:

A. Neuroblastoma
B. Hepatoblastoma
C. Wilms tumor
D. Renal abscess

15. An adolescent presents with gross hematuria and flank mass. The tumor crosses the midline on
imaging. Diagnosis?

A. Wilms tumor
B. Neuroblastoma
C. Renal cyst
D. Rhabdomyosarcoma

16. A child presents with proptosis, epistaxis, and a rapidly growing nasal mass. This is characteristic
of:

A. Retinoblastoma
B. Rhabdomyosarcoma
C. Neuroblastoma
D. Non-Hodgkin lymphoma

17. A 7-year-old has pancytopenia, hepatosplenomegaly, and bone marrow infiltration by blasts.
Which test is most definitive for leukemia diagnosis?

A. CBC
B. Peripheral smear
C. Bone marrow biopsy
D. CT scan

18. A child has supraclavicular lymph node enlargement and mediastinal widening. Which cancer is
most likely?

A. Hodgkin lymphoma
B. Osteosarcoma
C. Retinoblastoma
D. Wilms tumor

19. A 6-year-old presents with café-au-lait spots and axillary freckling. Which childhood cancer is he at
increased risk of?

A. Neuroblastoma
B. Optic glioma
C. Hepatoblastoma
D. Ewing sarcoma

20. A 12-year-old presents with localized pain in the pelvis, fever, and leukocytosis. Imaging shows an
aggressive bone lesion with soft-tissue mass. Most likely diagnosis?

A. Osteosarcoma
B. Ewing sarcoma
C. Chronic osteomyelitis
D. Fibrosarcoma

ANSWER KEY + EXPLANATIONS

Derived from Childhood Cancers by Mig – Short

Childhood Cancers by Mig -Short

1. B — ALL
Most common leukemia; bone pain + hepatosplenomegaly + anemia.

2. B — ALL
ALL is the most common pediatric malignancy.
3. B — Wilms tumor
Smooth, unilateral, does not cross midline, + hypertension.

4. B — Metastatic spread
Periorbital ecchymosis is classic for metastatic neuroblastoma.

5. B — Retinoblastoma
Leukocoria is hallmark.

6. B — Hodgkin lymphoma
Reed-Sternberg cells + B symptoms.

7. A — Osteosarcoma
Distal femur + sunburst pattern.

8. B — T-cell ALL
Commonly presents with a mediastinal mass.

9. B — Neuroblastoma
Produces catecholamine metabolites (VMA/HVA).

10. B — Wilms tumor

WT1 mutation → Wilms tumor.

11. B — Cerebellum
Medulloblastoma is common in posterior fossa.

12. B — Ewing sarcoma

Onion-skin periosteal reaction.

13. B — Burkitt lymphoma

Jaw mass, abdominal masses, EBV association.

14. B — Hepatoblastoma
Infants + elevated AFP.

15. B — Neuroblastoma
Crosses midline; arises from adrenal medulla.

16. B — Rhabdomyosarcoma
Most common soft tissue sarcoma in children.

17. C — Bone marrow biopsy

Definitive confirmation.

18. A — Hodgkin lymphoma

Mediastinal mass + supraclavicular adenopathy.
 19. B — Optic glioma
Associated with NF1.

20. B — Ewing sarcoma

Pelvic tumor + systemic symptoms + soft-tissue mass.

1. A 2-month-old infant presents with tachypnea, poor feeding, diaphoresis

during feeds, and hepatomegaly. Which is the most likely diagnosis?

A. Sepsis
B. Heart failure
C. Asthma
D. Physiologic reflux

2. An infant with a large VSD develops heart failure at 6–8 weeks of life. Why
does HF typically appear at this age?

A. Pulmonary pressures increase

B. Pulmonary vascular resistance naturally falls
C. Ductus arteriosus closes
D. VSD enlarges gradually

3. A child with heart failure has cool extremities, weak pulses, and delayed cap
refill. This indicates:

A. High-output failure
B. Low-output failure
C. Right heart failure only
D. Normal perfusion

4. A 4-month-old with feeding difficulty and tachypnea has a gallop rhythm (S3).
What does S3 in children typically indicate?

A. Normal finding in infants

B. Early sign of congestive heart failure
C. Severe mitral stenosis
D. Innocent murmur
5. A 5-year-old presents with jugular venous distension, hepatomegaly, and
peripheral edema. Which type of heart failure is this?

A. Left-sided HF
B. Right-sided HF
C. High-output HF
D. Diastolic HF only

6. A child with HF from dilated cardiomyopathy has tachycardia, hypotension,

and cool extremities. What classification is this?

A. Warm and dry

B. Warm and wet
C. Cold and dry
D. Cold and wet

7. A child with HF is started on furosemide. What is the primary benefit?

A. Reduced heart rate

B. Reduced preload
C. Reduced afterload
D. Increased contractility

8. A 3-year-old with severe HF is started on an ACE inhibitor. What is the

reason ACE inhibitors are useful?

A. Increase heart rate

B. Reduce afterload and improve forward flow
C. Increase sodium retention
D. Cause pulmonary vasoconstriction

9. A child with HF due to myocarditis is treated with digoxin. Digoxin improves

cardiac function by:

A. Vasodilation of coronary arteries

B. Increasing myocardial contractility
C. Reducing HR only
D. Reducing blood volume

10. A 4-year-old with HF has hepatomegaly but no peripheral edema. This is

because:

A. Children rarely retain fluid

B. Children show earlier liver congestion than edema
C. It indicates liver failure only
D. The child is dehydrated

11. A child with HF has tachypnea without wheezing. CXR shows cardiomegaly.
What is the most likely cause of tachypnea?

A. Pneumonia
B. Reactive airway disease
C. Pulmonary congestion from HF
D. Foreign body aspiration

12. Which lab abnormality is commonly seen in severe HF?

A. Hypernatremia
B. Hyponatremia (due to water retention & ADH)
C. Hyperkalemia always
D. Hypoglycemia

13. A child with HF due to a large PDA has pulmonary overcirculation. Which is
the best long-term treatment?

A. High-dose diuretics forever

B. Closure of PDA
C. Steroid therapy
D. Anticoagulation only
14. A term baby develops HF on day 2 of life. CXR: cardiomegaly, increased
pulmonary blood flow. Which CHD most commonly causes HF in the newborn
period?

A. VSD
B. PDA
C. HLHS (duct-dependent systemic circulation)
D. ASD

15. A child with HF is noted to have excessive sweating, especially during feeding.
The mechanism is:

A. Fever
B. Autonomic activation due to low cardiac output
C. Hypoglycemia
D. Hyperthyroidism

16. A 7-year-old with DCM has worsening HF despite optimal therapy. BNP is
elevated. What does BNP reflect?

A. Myocardial necrosis
B. Ventricular wall stretch
C. Lung injury
D. Renal failure

17. A 10-year-old presents with fatigue and dyspnea. ECG shows low-voltage
QRS and echo shows small ventricles with bi-atrial enlargement. Diagnosis?

A. DCM
B. RCM
C. HCM
D. PDA

18. A child with HF from myocarditis has severe bradycardia. What is the next
step?
A. Beta blockers
B. Atropine
C. Calcium channel blockers
D. Observe only

19. A child with HF due to ARF carditis has severe MR and tachycardia. What is
the preferred therapy?

A. NSAIDs only
B. Corticosteroids plus HF management
C. Surgery immediately
D. No anti-inflammatory needed

20. A child in severe decompensated HF has hypotension and signs of shock.

Most appropriate next step?

A. Oral diuretics only

B. IV inotropes (e.g., milrinone/dobutamine)
C. Beta blockers
D. ACE inhibitors first

ANSWERS + EXPLANATIONS
1. B — Heart failure
Tachypnea + diaphoresis with feeds + hepatomegaly = classic HF signs.

2. B — Pulmonary vascular resistance falls

This allows large L→R shunts (like VSD) to become symptomatic.

3. B — Low-output HF
Cool extremities + weak pulses = poor perfusion.

4. B — Early sign of CHF

S3 in children indicates volume overload and HF.

5. B — Right-sided HF
Systemic venous congestion → edema, hepatomegaly, JVD.
6. D — Cold and wet
Cold = poor perfusion; wet = congestion.

7. B — Reduced preload
Loop diuretics reduce intravascular volume.

8. B — Reduce afterload
ACE inhibitors improve forward cardiac output.

9. B — Increase contractility
Digoxin → positive inotrope.

10. B — Earlier liver congestion

Edema develops late; hepatomegaly appears first.

11. C — Pulmonary congestion

Tachypnea without wheeze = CHF pulmonary venous congestion.

12. B — Hyponatremia
Due to ADH activation and water retention in HF.

13. B — PDA closure

Fixing the cause of HF is the treatment.

14. C — HLHS
Newborn HF strongly suggests duct-dependent lesions.

15. B — Autonomic activation

Sweating during feeds = sympathetic response to low CO.

16. B — Ventricular stretch

BNP is secreted due to wall stress.

17. B — Restrictive cardiomyopathy

Small stiff ventricles + large atria.

18. B — Atropine
Treats symptomatic bradycardia in HF.

19. B — Steroids + HF therapy

ARF severe carditis → corticosteroids improve inflammation.

20. B — IV inotropes
Used in cardiogenic shock or severe decompensation.
20 Case-Based MCQs — Infective
Endocarditis

1. A 12-year-old boy with a history of unrepaired VSD presents with 2 weeks of

fever, weight loss, and a new regurgitant murmur. Which is the MOST
important next step for diagnosis?

A. ESR only
B. One blood culture
C. Three blood cultures from separate sites
D. Echocardiography only

2. A child with IE has painless erythematous macules on palms and soles. These
lesions are called:

A. Osler nodes
B. Janeway lesions
C. Roth spots
D. Splinter hemorrhages

3. Painful, erythematous nodules on fingertips and toes in IE are:

A. Janeway lesions
B. Osler nodes
C. Erythema marginatum
D. Hives

4. IE in children is MOST commonly caused by:

A. Gram-negative rods
B. Staphylococcus aureus and viridans streptococci
C. Anaerobes
D. Fungi
5. A 15-year-old IV drug user presents with fever and cough. CXR shows
multiple nodular lesions suggestive of septic emboli. Which valve is most likely
infected?

A. Mitral
B. Aortic
C. Tricuspid
D. Pulmonic

6. A child with prosthetic valve IE develops symptoms 3 months after valve

surgery. This is classified as:

A. Native valve acute IE

B. Early prosthetic valve IE
C. Late prosthetic valve IE
D. Nosocomial IE only

7. The MOST common cardiac condition predisposing to IE in children is:

A. Atrial septal defect

B. Cyanotic congenital heart disease
C. Innocent murmur
D. Hypertrophic cardiomyopathy

8. A child with IE presents with hematuria and proteinuria. The renal findings
are due to:

A. Direct bacterial invasion

B. Immune complex deposition (glomerulonephritis)
C. Drug toxicity
D. Trauma

9. Splinter hemorrhages in IE are:

A. Pathognomonic
B. Nonspecific signs of microembolization
C. Due to warfarin toxicity
D. Due to anemia

10. Which organism is common in prosthetic valve IE?

A. Viridans streptococci
B. Coagulase-negative staphylococci (S. epidermidis)
C. HACEK organisms
D. Enterococcus faecalis

11. A child with IE has stroke symptoms. The most likely mechanism is:

A. Septic embolization from a vegetation

B. Myocardial infarction
C. CNS vasculitis
D. Hypertension

12. Which is the MOST significant risk factor for IE in a postoperative child?

A. Fever
B. Presence of foreign material (patches, shunts, central lines)
C. Electrolyte abnormalities
D. Anemia

13. A child with fever, new murmur, and a vegetation on echo PLUS positive
blood cultures meets criteria for:

A. Possible IE
B. Definite IE (Duke criteria)
C. No IE
D. Only minor criteria

14. Management of IE requires antibiotics for:

A. 3–5 days
B. 1 week
C. 4–6 weeks of IV therapy
D. Oral therapy only

15. A child with congenital heart disease asks about IE prophylaxis. Which
procedure REQUIRES antibiotic prophylaxis?

A. Routine dental cleaning

B. Ear piercing
C. Minor skin abrasions
D. GI endoscopy without biopsy

16. Janeway lesions are best described as:

A. Painful purple nodules

B. Painless blanching erythematous macules on palms/soles
C. Retinal hemorrhages with pale centers
D. Nail bed hemorrhages

17. A patient hospitalized for >48 hours develops signs of IE. This is classified as:

A. Community-acquired IE
B. Healthcare-associated (nosocomial) IE
C. IVDA-associated
D. Unknown

18. HACEK organisms are characterized by being:

A. Non-bacterial causes
B. Fastidious gram-negative organisms from the oropharynx
C. Anaerobic fungi
D. Normal skin flora

19. A child with CHD presents with prolonged fever but no murmur and no
embolic signs. Echocardiogram is normal but suspicion is high. Next step?
A. Stop evaluation
B. Repeat echo in several days
C. Immediate surgery
D. Give steroids

20. The most important determinant of prognosis in IE is:

A. ESR level
B. Degree of valvular damage/heart failure
C. Duration of fever
D. Anemia severity

ANSWERS + EXPLANATIONS
Based on Infective Endocarditis by [Link].

Infective Endocarditis By Mig

1. C — Three blood cultures

Multiple cultures from different sites increase diagnostic yield.

2. B — Janeway lesions

Painless, blanching macules on palms/soles.

3. B — Osler nodes

Painful nodules caused by immune complex deposition.

4. B — S. aureus & viridans streptococci

Most common organisms in pediatric IE.

5. C — Tricuspid

IV drug use → right-sided IE → septic pulmonary emboli.

6. B — Early prosthetic valve IE

Defined as occurring <1 year after valve replacement.

7. B — Cyanotic CHD

35–50% of children with IE have CHD, especially cyanotic.

8. B — Immune complex GN

Renal involvement due to immune-mediated injury.

9. B — Nonspecific

They indicate microvascular emboli but are not specific for IE.

10. B — Coagulase-negative staphylococci

Especially S. epidermidis in prosthetic valves.

11. A — Septic embolization

Vegatations embolize to cerebral vessels.

12. B — Prosthetic material/lines

Foreign materials increase risk substantially.

13. B — Definite IE

Major + major = definite diagnosis.

14. C — 4–6 weeks IV antibiotics

Standard therapy duration.

15. A — Dental procedures

Prophylaxis indicated in high-risk CHD patients for dental work involving gingiva.

16. B — Painless blanching macules

Classic description of Janeway lesions.

17. B — Nosocomial IE
≥48 h hospitalization before symptoms.

18. B — Fastidious oropharyngeal GNBs

HACEK: Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella.

19. B — Repeat echo

Early echo may miss vegetations; repeat in 3–7 days.

20. B — Severity of valvular dysfunction/heart failure

Main determinant of morbidity and mortality.

20 Case-Based MCQs — Kawasaki Disease

1. A 2-year-old child presents with 5 days of high fever, bilateral non-purulent

conjunctivitis, strawberry tongue, erythematous rash, and cervical
lymphadenopathy. What is the most likely diagnosis?

A. Scarlet fever
B. Kawasaki disease
C. Viral exanthem
D. Measles

2. A child with suspected KD has desquamation of fingers and toes during week 3
of illness. This corresponds to which phase?

A. Acute febrile phase

B. Subacute phase
C. Convalescent phase
D. Chronic phase

3. Which age group is MOST affected by KD?

A. Teenagers
B. Infants <1 month
C. Children under 5 years
D. Adults

4. The most serious complication of KD is:

A. Pneumonia
B. Coronary artery aneurysm
C. Encephalitis
D. Seizures

5. A 4-year-old has KD and is extremely irritable, has thrombocytosis, and

periungual peeling. What phase is this?

A. Acute
B. Subacute
C. Convalescent
D. Recovery

6. A child presents with fever for 7 days and 4 of 5 principal KD clinical signs.
What is needed for diagnosis of complete KD?

A. All 5 signs
B. At least 4 of 5 signs + fever ≥5 days
C. Only coronary aneurysm
D. Elevated platelets

7. A 3-year-old with KD has very high platelets (1 million/µL). Which phase does
thrombocytosis occur in?

A. Only in convalescent
B. Only in acute
C. Subacute
D. Only before fever begins

8. What is the first-line treatment for acute Kawasaki disease?

A. High-dose steroids alone
B. IVIG + high-dose aspirin
C. IV antibiotics
D. Low-dose aspirin only

9. A child is diagnosed with KD on day 6 of illness. When should IVIG be given

for best prevention of coronary aneurysms?

A. Only after day 10

B. Within the first 10 days of illness
C. After platelet count rises
D. Only if fever recurs

10. A child with KD continues to have fever 48 hours after IVIG treatment. Next
step?

A. Give a second dose of IVIG

B. Start antibiotics
C. Stop aspirin
D. Observe only

11. A child with KD in the acute phase develops gallbladder hydrops. This
finding is:

A. Very rare and unrelated

B. Known complication of KD
C. Diagnostic of appendicitis
D. Seen only with bacterial sepsis

12. A patient with fever, conjunctivitis, mucositis, and rash tests positive for
adenovirus. Can KD still be diagnosed?

A. No—viral infection excludes KD

B. Yes—viral detection does not exclude KD
C. Only if ESR is normal
D. Only if no lymphadenopathy
13. "Strawberry tongue" in KD is due to:

A. Vitamin deficiency
B. Mucosal erythema and papillary enlargement
C. Viral infection
D. Corticosteroid use

14. A child is in the convalescent phase of KD. Which feature is most typical?

A. Persistent fever
B. High ESR
C. Normalizing labs + Beau lines on nails
D. Rash spreading

15. Which of the following is TRUE about incomplete KD?

A. Occurs mostly in adults

B. Occurs in infants who meet some but not all criteria
C. Has no risk of coronary aneurysm
D. Always requires biopsy for diagnosis

16. A newborn sibling of a child with KD is being evaluated. Which is TRUE

about KD epidemiology?

A. Genetic predisposition is unlikely

B. Siblings have increased risk
C. It is caused by a single known pathogen
D. It is more common in adults

17. A 3-year-old with KD in the subacute phase is at highest risk for:

A. Viral infection
B. Coronary artery aneurysm
C. Septic shock
D. Renal failure
18. Which test is essential at diagnosis and follow-up of KD?

A. Brain MRI
B. Echocardiography
C. Chest X-ray
D. Liver ultrasound

19. A 2-year-old with KD develops MI. What is the likely cause?

A. Vasculitis of pulmonary arteries

B. Thrombosis or stenosis of coronary aneurysm
C. Aortic dissection
D. Viral myocarditis

20. A child treated for KD with IVIG asks about vaccines. Which is true?

A. No vaccines are affected

B. Live vaccines should be delayed for ~11 months after IVIG
C. All vaccines must be stopped indefinitely
D. Only flu vaccine is delayed

ANSWERS + EXPLANATIONS
Based on Kawasaki Diseases by [Link].

Kawasaki Diseases by Mig

1. B — Kawasaki disease

Fever ≥5 days + ≥4 principal features.

2. B — Subacute phase

Weeks 2–4 → peeling of digits, thrombocytosis, risk of CA aneurysm.

3. C — Children under 5 years

85–90% of cases occur <5 years old.

4. B — Coronary artery aneurysm

Most feared complication; can cause thrombosis/MI.

5. B — Subacute phase

Hallmarks: desquamation, thrombocytosis, irritability.

6. B — 4 of 5 signs + fever ≥5 days

This is diagnostic of complete KD.

7. C — Subacute

Platelets peak in subacute phase (up to >1 million).

8. B — IVIG + high-dose aspirin

Standard first-line therapy.

9. B — Within first 10 days

Best aneurysm prevention occurs when given before day 10.

10. A — Give second dose IVIG

Refractory KD → repeat IVIG or consider steroids.

11. B — Known complication

Gallbladder hydrops occurs in acute KD.

12. B — Viral detection does NOT exclude KD

Many respiratory viruses may coexist.

13. B — Erythematous mucosa + enlarged papillae

Classic strawberry tongue.

14. C — Normalizing labs + Beau lines

Convalescent phase = healing phase.

15. B — Seen in infants with partial criteria

Incomplete KD still carries aneurysm risk.

16. B — Siblings have increased risk

Genetic & familial clustering is documented.

17. B — Coronary aneurysm risk highest

Occurs during subacute phase.

18. B — Echocardiography

Main tool to detect CA aneurysms.

19. B — Thrombosis/stenosis of aneurysm

MI is due to occlusion of a coronary aneurysm.

20. B — Delay live vaccines ~11 months

IVIG interferes with live vaccine immunity.

20 Case-Based MCQs — MI in Children /

Pediatric ACS

1. A 13-year-old boy presents with sudden severe chest pain radiating to the left
arm, sweating, and nausea. ECG shows ST-segment elevation in leads V2–V5.
What is the diagnosis?

A. Pericarditis
B. STEMI
C. NSTEMI
D. Panic attack
2. Which cardiac biomarker is MOST sensitive and specific for diagnosing MI in
children?

A. CK-MB
B. Troponin I/T
C. Myoglobin
D. LDH

3. A 15-year-old with chest pain has ST depression and elevated troponins.

Diagnosis?

A. STEMI
B. NSTEMI
C. Angina only
D. Myocarditis

4. A child with Kawasaki disease complications develops sudden chest pain and
ECG changes. What is the most likely cause?

A. Viral pneumonia
B. Coronary artery aneurysm thrombosis
C. Asthma
D. Pulmonary hypertension

5. A 10-year-old with nephrotic syndrome on chronic steroids presents with MI.

Which risk factor applies?

A. Hypotension
B. Hypercoagulability
C. Hypocalcemia
D. Low cholesterol

6. Which of the following is NOT a cause of MI in children?

A. Coronary artery anomalies

B. Thrombosis in CA aneurysm
C. Atherosclerosis from fatty streaks
D. Drug use (cocaine)

7. A newborn in shock has ECG changes suggestive of ischemia. He has a history

of asphyxia at birth. What is the probable cause of MI?

A. Coronary artery spasm

B. Hypoxic-ischemic injury
C. Metabolic bone disease
D. Hypothyroidism

8. Chest pain in MI is classically described as:

A. Sharp and positional

B. Heavy, pressure-like, may radiate
C. Worse on inspiration
D. Localized pinpoint tenderness

9. A teenager collapses after using cocaine. ECG shows ST elevation. Mechanism

of MI?

A. Coronary vasospasm
B. Aortic stenosis
C. Pericarditis
D. Pulmonary embolism

10. A 12-year-old with familial hypercholesterolemia presents with MI. The

underlying pathology is:

A. Vasculitis of small arteries

B. Premature atherosclerosis
C. Fatty liver
D. Renal artery stenosis
11. A child with chest pain has elevated high-sensitivity troponins but no ST
elevation. According to current classification, this is:

A. Angina
B. NSTEMI
C. Stable angina
D. Normal

12. A 14-year-old with MI has arrhythmia on presentation. Which is the most

common arrhythmia seen in MI?

A. Atrial fibrillation
B. Ventricular tachycardia/fibrillation
C. SVT
D. Heart block

13. Pain radiating to the back, neck, or jaw in a pediatric patient is typical of:

A. Reflux
B. Pericarditis
C. Myocardial ischemia
D. Asthma

14. The earliest ECG change in MI is usually:

A. Q waves
B. ST-segment elevation
C. Peaked (hyperacute) T waves
D. T-wave inversion

15. A child with MI shows ST elevation in II, III, aVF. Which region is affected?

A. Anterior
B. Inferior
C. Lateral
D. Septal
16. A pediatric patient with suspected MI should first receive which emergency
medication (if no contraindication)?

A. Aspirin
B. Digoxin
C. Steroids
D. Furosemide

17. A 6-year-old with a large coronary artery aneurysm (post-Kawasaki)

develops MI. What is the definitive treatment?

A. NSAIDs
B. Anticoagulation ± thrombolysis
C. Only fluids
D. Antibiotics

18. Which pediatric population is MOST at risk for MI due to

hypercoagulability?

A. ASD patients
B. Children with nephrotic syndrome
C. Down syndrome
D. Cystic fibrosis

19. A child with MI has persistent ST elevation and LV dysfunction. What late
complication may develop?

A. Myocarditis
B. Ventricular aneurysm
C. Asthma
D. Pleural effusion

20. A child with MI is noted to have papillary muscle dysfunction. What valvular
problem is expected?
A. Mitral regurgitation
B. Aortic stenosis
C. Pulmonic regurgitation
D. Tricuspid stenosis

ANSWERS + EXPLANATIONS
Based on MI in Children by [Link].

MI in Children By Mig

1. B — STEMI

ST-elevation in V2–V5 = anterior wall STEMI.

2. B — Troponins

Most sensitive/specific test for myocardial injury.

3. B — NSTEMI

Non–ST elevation + high troponins.

4. B — Coronary aneurysm thrombosis

KD → aneurysm → thrombosis → MI.

5. B — Hypercoagulability

Nephrotic syndrome → ↑ risk of thrombosis.

6. C — Atherosclerosis from fatty streaks

Classic adult atherosclerosis is rare in children.

7. B — Hypoxic-ischemic injury

Birth asphyxia → global myocardial ischemia.

8. B — Heavy/pressure-like
Classic MI description.

9. A — Coronary vasospasm

Cocaine → intense vasospasm → MI.

10. B — Premature atherosclerosis

Seen in familial hypercholesterolemia.

11. B — NSTEMI

Troponin elevation = necrosis even without ST elevation.

12. B — Ventricular tachycardia/fibrillation

Most dangerous arrhythmias in MI.

13. C — Myocardial ischemia

Typical radiation pattern.

14. C — Hyperacute T waves

Earliest ischemic ECG change.

15. B — Inferior wall MI

II, III, aVF = inferior leads.

16. A — Aspirin

Initial antiplatelet therapy if MI suspected.

17. B — Anticoagulation ± thrombolysis

Coronary aneurysm thrombosis requires aggressive management.

18. B — Nephrotic syndrome

High risk of thromboembolism.

19. B — Ventricular aneurysm

Result of persistent ST elevation + necrotic wall.

20. A — Mitral regurgitation

Papillary muscle ischemia → acute MR.

1. A 3-year-old with fever, weight loss, and a large abdominal mass has
calcifications on CT and elevated VMA/HVA. What is the diagnosis?

A. Wilms tumor
B. Neuroblastoma
C. Hepatoblastoma
D. Lymphoma

2. A child with neuroblastoma presents with opsoclonus-myoclonus (“dancing

eyes, dancing feet”). What does this indicate?

A. Early-stage disease
B. Paraneoplastic syndrome
C. Cerebral palsy
D. Seizure disorder

3. A 7-year-old presents with headaches and precocious puberty. Which brain

tumor is most likely?

A. Craniopharyngioma
B. Medulloblastoma
C. Astrocytoma
D. Ependymoma

4. A toddler has a flank mass, hematuria, and aniridia. Which syndrome is

associated?

A. WAGR syndrome
B. NF1
C. Beckwith-Wiedemann
D. Li-Fraumeni
5. A 10-year-old with persistent bone pain, fever, and a lytic lesion at the mid-
shaft of femur is suspected of having Ewing sarcoma. Which translocation is
classic?

A. t(11;22)
B. t(9;22)
C. t(15;17)
D. t(8;14)

6. A child presents with abdominal mass, tongue protrusion, and gigantism.

Which cancer is associated with Beckwith-Wiedemann syndrome?

A. Retinoblastoma
B. Neuroblastoma
C. Wilms tumor
D. Osteosarcoma

7. A 5-year-old presents with painless lymphadenopathy, fever, and weight loss.

Pel-Ebstein fever is characteristic of:

A. Hodgkin lymphoma
B. Burkitt lymphoma
C. ALL
D. AML

8. A child with ALL begins treatment and develops tumor lysis syndrome. Which
finding is expected?

A. Hypokalemia
B. Hyperuricemia
C. Hypophosphatemia
D. Hypercalcemia

9. A 6-year-old presents with ear discharge, skull lesions, and diabetes insipidus.
Most likely diagnosis?
A. Neuroblastoma
B. Langerhans cell histiocytosis
C. Osteosarcoma
D. Meningioma

10. The most common solid tumor of childhood (outside CNS) is:

A. Wilms tumor
B. Neuroblastoma
C. Hepatoblastoma
D. Retinoblastoma

11. A child with Burkitt lymphoma undergoes biopsy. Which pathological

feature is classic?

A. Rosenthal fibers
B. Reed-Sternberg cells
C. Starry-sky appearance
D. Homer Wright rosettes

12. A 15-year-old boy presents with a painful mass around the knee. Alkaline
phosphatase is elevated. Most likely diagnosis?

A. Osteosarcoma
B. Rhabdomyosarcoma
C. Ewing sarcoma
D. Osteomyelitis

13. A child presents with abdominal pain, jaundice, and very high AFP levels.
Which tumor is suspected?

A. Hepatoblastoma
B. Neuroblastoma
C. Wilms tumor
D. Medulloblastoma
14. A teenager presents with painless testicular enlargement. Which cancer is
most likely?

A. Leydig cell tumor

B. Teratoma
C. Germ cell tumor
D. Wilms tumor

15. A child presents with ataxia, morning headaches, and vomiting. MRI shows a
midline cerebellar tumor. Diagnosis?

A. Medulloblastoma
B. Craniopharyngioma
C. Pituitary adenoma
D. Astrocytoma (hemispheric)

16. A child with ALL is treated with daunorubicin and develops cardiotoxicity.
Which organ is primarily affected?

A. Liver
B. Kidneys
C. Heart
D. Lungs

17. A 5-year-old presents with abdominal mass, hypertension, and elevated renin.
Which tumor is associated with renin secretion?

A. Wilms tumor
B. Neuroblastoma
C. Hepatoblastoma
D. Rhabdomyosarcoma

18. Bilateral retinoblastoma greatly increases risk of which second malignancy?

A. Lung cancer
B. Osteosarcoma
C. Colon cancer
D. Wilms tumor

19. A child with a mediastinal mass develops superior vena cava syndrome.
Which cancer is most likely?

A. T-cell ALL
B. Osteosarcoma
C. Wilms tumor
D. Retinoblastoma

20. A 4-year-old with abdominal pain is found to have a “double bubble”

appearance on X-ray and hepatomegaly with elevated AFP. What is the most
likely diagnosis?

A. Hirschsprung disease
B. Hepatoblastoma
C. Wilms tumor
D. Duodenal atresia only

ANSWERS + EXPLANATIONS
Based on Childhood Cancers by Mig – Short

Childhood Cancers by Mig -Short

1. B — Neuroblastoma

Calcifications + elevated VMA/HVA = neuroblastoma.

2. B — Paraneoplastic syndrome

Opsoclonus–myoclonus is classic paraneoplastic neurological syndrome.

3. A — Craniopharyngioma
Causes endocrine dysfunction and visual issues.

4. A — WAGR syndrome

Wilms, Aniridia, Genitourinary anomalies, Retardation.

5. A — t(11;22)

Ewing sarcoma translocation.

6. C — Wilms tumor

Beckwith-Wiedemann → macroglossia + Wilms risk.

7. A — Hodgkin lymphoma

Pel-Ebstein fever is characteristic.

8. B — Hyperuricemia

TLS causes hyperuricemia, hyperphosphatemia, hyperkalemia.

9. B — Langerhans cell histiocytosis

Classic triad: bone lesions, DI, exophthalmos.

10. B — Neuroblastoma

Most common extracranial solid tumor of childhood.

11. C — Starry-sky appearance

Burkitt lymphoma pathology.

12. A — Osteosarcoma

Painful metaphyseal tumor; ↑ ALP.

13. A — Hepatoblastoma

Most common liver tumor with high AFP.

14. C — Germ cell tumor

Most common malignant testicular tumor in children.

15. A — Medulloblastoma

Highly malignant midline cerebellar tumor.

16. C — Heart

Anthracyclines → dose-dependent cardiotoxicity.

17. A — Wilms tumor

Can produce renin → hypertension.

18. B — Osteosarcoma

RB1 mutation predisposes to bone tumors.

19. A — T-cell ALL

Often presents with mediastinal mass causing SVC syndrome.

20. B — Hepatoblastoma

Presents with abdominal mass, ↑AFP; “double bubble” may coincide with mass effect.

1. A 3-year-old child presents with abdominal distension, a firm non-tender mass

that does not cross the midline, and hypertension. Which cancer is most likely?

A. Wilms tumor
B. Neuroblastoma
C. Hepatoblastoma
D. Lymphoma

2. A 5-year-old boy presents with fever, night sweats, weight loss, and painless
cervical lymphadenopathy. Biopsy shows Reed–Sternberg cells. Diagnosis?

A. Non-Hodgkin lymphoma
B. Hodgkin lymphoma
C. Leukemia
D. TB lymphadenitis
3. A 2-year-old presents with white pupillary reflex (leukocoria) on photos. What
is the most likely diagnosis?

A. Retinoblastoma
B. Cataract
C. Retinal detachment
D. Congenital glaucoma

4. A child with acute leukemia presents with anemia, thrombocytopenia, and

neutropenia. What is this triad called?

A. Bone marrow suppression

B. Pancytopenia
C. Sepsis
D. Myelodysplasia

5. A child with abdominal pain, weight loss, proptosis, and periorbital

ecchymosis most likely has:

A. Wilms tumor
B. Retinoblastoma
C. Neuroblastoma
D. Rhabdomyosarcoma

6. A 4-year-old presents with bone pain, fever, pallor, hepatosplenomegaly, and

blasts on smear. Diagnosis?

A. AML
B. CML
C. ALL
D. MDS

7. Which childhood cancer is associated with t(9;22) BCR-ABL?

A. ALL (some subtypes)

B. AML M3
C. Neuroblastoma
D. Wilms tumor

8. A 6-year-old presents with painless abdominal mass, sometimes crossing the

midline, and elevated VMA/HVA. Diagnosis?

A. Wilms tumor
B. Neuroblastoma
C. Renal cell carcinoma
D. Teratoma

9. A mother notes that her child’s abdomen looks swollen. Exam reveals a
smooth, unilateral flank mass that DOES cross the midline, hematuria, and
hypertension. Diagnosis?

A. Neuroblastoma
B. Wilms tumor
C. Hepatoblastoma
D. Lymphoma

10. A child with progressive back pain, urinary retention, and lower limb
weakness. MRI shows a mass compressing the spinal cord. Most likely cause?

A. Osteosarcoma
B. Spinal metastasis from neuroblastoma
C. Epidural abscess
D. Vertebral fracture

11. A 10-year-old presents with a painful swelling near the knee, sunburst
pattern on X-ray. Diagnosis?

A. Osteosarcoma
B. Ewing sarcoma
C. Osteomyelitis
D. Rickets
12. A 7-year-old with diaphyseal bone pain has an X-ray showing onion-skin
pattern. Diagnosis?

A. Ewing sarcoma
B. Osteosarcoma
C. Osteomyelitis
D. Langerhans cell histiocytosis

13. A 3-year-old girl presents with a newly noticed abdominal mass. Ultrasound
shows a renal origin. What is the next best step?

A. Biopsy first
B. Immediate chemotherapy
C. Abdominal CT and chest imaging
D. No imaging needed

14. A child with hepatoblastoma typically has elevated:

A. LDH
B. AFP
C. β-hCG
D. CK

15. A 2-year-old presents with café-au-lait spots, multiple neurofibromas, and

optic glioma. Diagnosis?

A. Tuberous sclerosis
B. Neurofibromatosis type 1
C. VHL disease
D. MEN syndrome

16. A 3-year-old boy presents with an abdominal mass and aniridia. Which
cancer is associated?

A. Hepatoblastoma
B. Wilms tumor
C. Neuroblastoma
D. Retinoblastoma

17. A patient with retinoblastoma is at increased risk for:

A. Osteosarcoma
B. AML
C. Chordoma
D. Teratoma

18. Tumor lysis syndrome presents with all EXCEPT:

A. Hyperkalemia
B. Hyperphosphatemia
C. Hypouricemia
D. Hypocalcemia

19. A 12-year-old presents with fever, weight loss, and mediastinal mass.
Superior vena cava syndrome is suspected. Most likely diagnosis?

A. T-cell ALL
B. AML
C. Ewing sarcoma
D. Retinoblastoma

20. A child in chemotherapy develops fever and neutropenia (ANC <500). Best
next step?

A. Observe
B. Immediate broad-spectrum IV antibiotics
C. Start steroids
D. Stop all medications

ANSWERS + EXPLANATIONS
1. B — Neuroblastoma

Classically non-tender, does not cross midline, ↑ catecholamines.

2. B — Hodgkin lymphoma

Reed–Sternberg cells confirm it.

3. A — Retinoblastoma

White reflex = leukocoria.

4. B — Pancytopenia

Caused by marrow infiltration.

5. C — Neuroblastoma

Periorbital ecchymosis = “raccoon eyes.”

6. C — ALL

Most common leukemia in children.

7. A — ALL

Philadelphia chromosome may appear in high-risk ALL.

8. B — Neuroblastoma

Midline crossing + high VMA/HVA.

9. B — Wilms tumor

Smooth firm renal mass that may cross midline.

10. B — Neuroblastoma metastasis

Common cause of spinal cord compression.

11. A — Osteosarcoma

Sunburst pattern + pain near knee.

12. A — Ewing sarcoma

Onion-skin pattern.

13. C — CT abdomen + chest

Staging needed before management.

14. B — AFP

Marker for hepatoblastoma.

15. B — NF-1

Café-au-lait + optic gliomas.

16. B — Wilms tumor

WAGR syndrome: Wilms, Aniridia, GU anomalies, Retardation.

17. A — Osteosarcoma

Associated with germline RB1 mutation.

18. C — Hypouricemia

TLS causes HYPERuricemia, not hypo.

19. A — T-cell ALL

Causes mediastinal mass + SVC syndrome.

20. B — Immediate IV antibiotics

Neutropenic fever = medical emergency.

20 Case-Scenario MCQs — Combined:

Anemia, Hemophilia & Polycythemia

1. A 2-year-old child presents with pallor, irritability, PICA, and spoon-shaped

nails. CBC shows low Hb and low MCV. What is the most likely diagnosis?
A. Iron deficiency anemia
B. Hemolytic anemia
C. Polycythemia
D. Vitamin B12 deficiency

2. A 10-year-old boy presents with fatigue, tachycardia, and Hb of 4 g/dL. He has

signs of heart failure. What is the most appropriate immediate treatment?

A. Iron supplementation
B. Packed RBC transfusion
C. Oral folic acid
D. Vitamin B12 injection

3. A child with iron deficiency anemia is started on ferrous sulfate. What is the
recommended dose?

A. 1 mg/kg/day
B. 2 mg/kg/day
C. 6 mg/kg/day
D. 10 mg/kg/day

4. A 4-year-old with chronic diarrhea and malnutrition has macrocytic anemia.

Which deficiency is MOST likely?

A. Iron
B. Folate
C. Vitamin C
D. Vitamin D

5. A 7-year-old boy presents with recurrent nosebleeds, prolonged PTT, normal

PT, and normal platelet count. What is the most likely diagnosis?

A. Hemophilia A
B. Thrombocytopenia
C. DIC
D. Vitamin K deficiency
6. A 3-year-old boy develops severe swelling of the knee after a minor fall. The
swelling is warm, painful, and he refuses to move the joint. What is the
condition?

A. Septic arthritis
B. Hemarthrosis
C. Osteomyelitis
D. Juvenile arthritis

7. A 5-year-old boy with hemophilia A is bleeding after a dental procedure. Best

treatment?

A. Platelet transfusion
B. Factor VIII replacement
C. Fresh frozen plasma
D. NSAIDs

8. A child with hemophilia has hematuria and painful swelling, but no trauma.
What should be avoided?

A. Rest
B. Ibuprofen
C. Ice
D. Factor replacement

9. A child receiving factor VIII replacement still has prolonged PTT. What is the
most concerning complication?

A. Liver failure
B. Inhibitor development
C. Iron overload
D. Hyponatremia
10. A 14-year-old boy has headache, dizziness, facial redness, pruritus after a
warm bath, and splenomegaly. CBC: Hb 20 g/dL, Hct 60%. Most likely
diagnosis?

A. Iron deficiency anemia

B. Polycythemia vera
C. Hemolytic anemia
D. Leukemia

11. A newborn with cyanotic heart disease has high Hb and Hct. Cause of
secondary polycythemia?

A. Bone marrow failure

B. High erythropoietin
C. Infection
D. Vitamin deficiency

12. A child with polycythemia complains of blurred vision and tingling in hands.
The most appropriate acute treatment is:

A. Iron therapy
B. Phlebotomy
C. Factor VIII
D. Steroids

13. A child with suspected anemia has low Hb and high TIBC. What type of
anemia?

A. Iron deficiency
B. Thalassemia
C. Chronic disease anemia
D. Sideroblastic anemia

14. A teenager shows low reticulocyte count, pancytopenia, and macrocytosis.

Which diagnosis fits?
A. Iron deficiency
B. Aplastic anemia
C. Hemolysis
D. Polycythemia

15. A 6-month-old infant with exclusive cow’s milk intake presents with
microcytic anemia. Cause?

A. Vitamin A excess
B. Low iron in cow milk
C. Excess folate
D. Viral infection

16. A 3-year-old boy presents with gum bleeding and prolonged bleeding after
minor cuts. Platelets are normal, PT normal, PTT prolonged. Treatment?

A. Vitamin K
B. Factor IX concentrate
C. Platelets
D. Desmopressin

17. A child with severe malnutrition develops severe anemia but iron therapy is
delayed until:

A. The child regains weight

B. One month passes
C. Hb rises spontaneously
D. Hydration is corrected

18. A child develops urticaria and wheezing during blood transfusion. First step?

A. Continue transfusion slowly

B. Stop transfusion immediately
C. Give aspirin
D. Start IV iron
19. Which complication is shared by hemophilia and polycythemia vera?

A. Thrombosis
B. Joint bleeding
C. Anemia
D. Leukopenia

20. A child with anemia due to hookworm infestation will typically show:

A. Macrocytosis
B. Eosinophilia + microcytic anemia
C. Leukopenia
D. Elevated B12

ANSWERS & EXPLANATIONS

1. A — Iron deficiency anemia

Classic signs: pallor, PICA, koilonychia, microcytosis.

2. B — Packed RBC transfusion

Indicated for severe anemia (Hb < 4 g/dL) or heart failure.

3. C — 6 mg/kg/day

Standard pediatric dose of elemental iron.

4. B — Folate

Macrocytic anemia is usually folate/B12 deficiency.

5. A — Hemophilia A

Prolonged PTT + normal PT + male child.

6. B — Hemarthrosis
Spontaneous joint bleeding is classic in hemophilia.

7. B — Factor VIII

Immediate replacement needed.

8. B — Avoid NSAIDs

NSAIDs worsen platelet function → ↑ bleeding.

9. B — Inhibitor development

Antibodies to factor VIII cause treatment resistance.

10. B — Polycythemia vera

High RBC mass, itching in warm bath, splenomegaly.

11. B — High EPO

Chronic hypoxia → secondary polycythemia.

12. B — Phlebotomy

First-line for symptomatic polycythemia.

13. A — Iron deficiency

High TIBC = low iron stores.

14. B — Aplastic anemia

Low RNC, RBC, WBC → marrow failure.

15. B — Low iron in cow milk

Major cause of infant microcytic anemia.

16. D — Desmopressin (DDAVP)

Effective for mild hemophilia A (raises factor VIII levels).

17. A — Wait until weight improves

Severely malnourished children cannot utilize iron until nutritional rehab begins.
18. B — Stop transfusion

First step in all transfusion reactions.

19. A — Thrombosis

Polycythemia → hyperviscosity;
Hemophilia (rarely) → thrombosis after factor infusion.

20. B — Eosinophilia + microcytosis

Hookworm causes chronic iron loss → microcytic anemia.

20 Case-Scenario MCQs (Anemia +

Hemophilia + Polycythemia)

1. A 2-year-old presents with pallor, irritability, and pica (eating soil). CBC
shows low Hb and low MCV. What is the most likely diagnosis?

A. Iron deficiency anemia

B. Hemolytic anemia
C. Thalassemia major
D. Polycythemia vera

2. A 5-year-old with severe anemia has tachycardia and signs of heart failure. Hb
= 3.5 g/dL. Best immediate management?

A. Start oral iron

B. Blood transfusion (Packed RBCs 10 ml/kg)
C. Begin folic acid only
D. Give IV fluids rapidly

3. A child has microcytic anemia and normal RDW. Family history positive for
anemia. Most likely?

A. Iron deficiency anemia

B. Thalassemia trait
C. B12 deficiency
D. Aplastic anemia

4. A 3-year-old has fatigue, glossitis, and macrocytosis. Best test to differentiate

folate vs B12 deficiency?

A. Platelet count
B. Serum ferritin
C. Serum B12 and folate levels
D. Reticulocyte count

5. A 4-year-old presents with recurrent epistaxis and hemarthrosis after minor

trauma. PT normal, PTT prolonged. Diagnosis?

A. Hemophilia A or B
B. Immune thrombocytopenia
C. Vitamin K deficiency
D. Leukemia

6. A boy with known Hemophilia A presents with knee swelling after falling
while playing. First-line treatment?

A. Aspirin
B. Factor VIII replacement
C. Fresh frozen plasma
D. Steroids only

7. A 9-year-old with hemophilia had dental extraction and now has prolonged
oozing. Which drug may help mild hemophilia A?

A. Desmopressin (DDAVP)
B. Warfarin
C. Iron supplement
D. NSAIDs
8. A 3-year-old with suspected hemophilia has prolonged bleeding after
circumcision. Which test is most indicative?

A. Low platelets
B. Low PT
C. Prolonged PTT with normal PT
D. Elevated WBC

9. A hemophilia patient presents with sudden headache, vomiting, and lethargy

after minor trauma. Most concerning complication?

A. Migraine
B. Intracranial hemorrhage
C. Sinusitis
D. Dehydration

10. A newborn with polycythemia (Hct 68%) shows irritability, feeding difficulty,
and reddish skin. The next step is:

A. Give oral iron

B. Immediate phlebotomy/partial exchange
C. Start aspirin
D. Begin hydroxyurea

11. A 12-year-old with cyanotic heart disease presents with high Hct (65%) and
headache. Cause of secondary polycythemia?

A. Bone marrow tumor

B. Increased erythropoietin due to hypoxia
C. Vitamin B12 deficiency
D. Dehydration

12. A 14-year-old with polycythemia vera has intense itching after hot showers.
This symptom is caused by:

A. Histamine release
B. Low iron
C. Heart failure
D. Infection

13. A child with severe polycythemia presents with blurry vision and
splenomegaly. Major risk?

A. Anemia
B. Thrombosis
C. Asthma
D. Hypoglycemia

14. A child with anemia has low Hb, low ferritin, high TIBC. Diagnosis?

A. Iron deficiency anemia

B. Anemia of chronic disease
C. Hemolytic anemia
D. Sickle cell disease

15. A 7-year-old presents with pallor, fever, bleeding gums. CBC shows
pancytopenia. Most likely:

A. Iron deficiency
B. Aplastic anemia
C. Polycythemia
D. Hemophilia

16. A child with anemia and malaria shows increased bilirubin and
reticulocytosis. Cause?

A. Nutritional deficiency
B. Hemolysis
C. Bone marrow failure
D. Dehydration
17. A 3-year-old with severe malnutrition shows anemia but is not started on iron
immediately. Why?

A. Iron worsens heart failure

B. Iron absorption poor during starvation
C. Iron causes hypoglycemia
D. Iron causes polycythemia

18. A hemophilia patient develops joint deformity from repeated hemarthrosis.

Long-term complication?

A. Chronic synovitis
B. Hypercalcemia
C. Osteoporosis only
D. Rickets

19. A child with polycythemia vera is given hydroxyurea. Purpose?

A. Increase WBC
B. Reduce RBC production
C. Increase platelets
D. Treat infections

20. A 4-year-old comes with fatigue; labs show Hb 5 g/dL but stable vitals, no
active bleeding. Best treatment?

A. IV iron
B. Oral iron 6 mg/kg/day
C. Exchange transfusion
D. Immediate surgery

ANSWERS + EXPLANATIONS

1. A — Iron deficiency anemia

Classic features: pallor + pica + low MCV.

2. B — Blood transfusion

Hb <4 g/dL = transfuse PRBCs urgently.

3. B — Thalassemia trait

Microcytosis with normal RDW → genetic.

4. C — Serum B12 and folate

Macrocytic anemia differentiation.

5. A — Hemophilia

Normal PT + prolonged PTT.

6. B — Factor VIII replacement

Standard for acute bleeds in Hemophilia A.

7. A — Desmopressin

Boosts factor VIII in mild Hemophilia A.

8. C — Prolonged PTT with normal PT

Classic for hemophilia.

9. B — Intracranial hemorrhage

Most dangerous complication.

10. B — Partial exchange

Reduces blood viscosity in symptomatic neonates.

11. B — Increased EPO from hypoxia

Secondary polycythemia.

12. A — Histamine release

Aquagenic pruritus in PV.

13. B — Thrombosis

High RBC mass → sluggish flow → clots.

14. A — Iron deficiency anemia

Low ferritin + high TIBC = IDA.

15. B — Aplastic anemia

Pancytopenia + fatigue + bleeding.

16. B — Hemolysis

Raises bilirubin + high retics.

17. B — Iron delayed until feeding improves

Refeeding increases utilization.

18. A — Chronic synovitis

Repeated hemarthrosis → joint damage.

19. B — Reduce RBC production

Hydroxyurea suppresses marrow.

20. B — Oral iron

Stable severe anemia without HF → treat IDA.

1. A 2-year-old child presents with fatigue, pallor, pica, and a low MCV. What is
the most likely diagnosis?

A. Thalassemia
B. Iron deficiency anemia
C. Aplastic anemia
D. Hemolytic anemia

2. A 4-year-old boy presents with swelling of the knee after minor trauma. PTT is
prolonged but PT is normal. Diagnosis?
A. Hemophilia A or B
B. Von Willebrand disease
C. Platelet disorder
D. Liver failure

3. A malnourished child started on iron supplementation developed no

improvement in Hb after 2 weeks. What is TRUE?

A. Iron failure rules out deficiency

B. Continue iron for at least 3–4 months
C. Switch to antibiotics
D. Stop iron immediately

4. A neonate develops heavy bleeding after circumcision. Family history

significant for maternal uncle with bleeding disorder. Most likely diagnosis:

A. Hemophilia (A or B)
B. Vitamin K deficiency
C. Thrombocytopenia
D. Sepsis

5. A child with severe anemia (Hb 3.8 g/dL) and signs of heart failure needs
immediate management. Next step:

A. High-dose folic acid

B. Packed RBC transfusion 10 mL/kg over 3–4 hrs
C. Oral iron only
D. Observation

6. A 6-year-old child has headache, dizziness, pruritus, flushing, and Hct of 60%.
What is the diagnosis?

A. Anemia
B. Polycythemia
C. Hemophilia
D. Thrombocytopenia
7. Polycythemia due to cyanotic congenital heart disease is classified as:

A. Primary
B. Secondary
C. Genetic
D. Congenital myeloproliferative

8. A child has normocytic anemia, hepatomegaly, and positive malaria smear.

Mechanism of anemia?

A. Reduced production
B. Increased RBC destruction
C. Blood loss
D. Hemodilution

9. A 10-year-old boy with hemophilia presents with elbow swelling, pain, and
limited motion. This is:

A. Soft-tissue infection
B. Hemarthrosis
C. Ligament tear
D. Osteomyelitis

10. Which lab pattern supports hemophilia?

A. Low platelets, prolonged PT

B. Normal PT, prolonged PTT
C. Normal PT and PTT
D. Prolonged PT only

11. A malnourished child with severe anemia should NOT start iron immediately
because:

A. Iron may cause vomiting

B. Iron must be delayed until child begins to eat and gain weight
C. Iron interacts with folic acid
D. Iron worsens infections

12. A child with polycythemia has Hct >55%, high RBCs, WBCs, and platelets.
Best immediate treatment?

A. High-dose steroids
B. Phlebotomy/venesection
C. Vitamin B12
D. Platelet transfusion

13. A 3-year-old boy with hematuria and hemophilia is given corticosteroids.

Why?

A. Increase factor VIII

B. Reduce inflammation
C. Treat hematuria
D. Treat infection

14. A child with anemia shows decreased serum iron and increased TIBC.
Diagnosis?

A. Anemia of chronic disease

B. Iron deficiency anemia
C. Thalassemia
D. Hemolytic anemia

15. A child receiving blood transfusion suddenly develops chills, fever, dyspnea,
and flank pain. First action?

A. Give antihistamine
B. Continue transfusion slowly
C. Stop transfusion immediately
D. Give IV fluids only
16. A 7-year-old boy with repeated joint bleeds has difficulty walking. Most likely
long-term complication?

A. Growth spurt
B. Chronic synovitis with joint damage
C. Muscle hypertrophy
D. Bone overgrowth

17. A child with hemophilia A is scheduled for dental extraction. What

medication is preferred?

A. Oral iron
B. Desmopressin (DDAVP)
C. Vitamin K
D. Platelets

18. A teenager with polycythemia complains of intense itching after hot showers.
This is due to:

A. Histamine release
B. Anemia
C. Hypocalcemia
D. Liver disease

19. A 6-year-old with severe anemia has tachycardia, lethargy, and growth delay.
Best diagnostic test?

A. Hb alone
B. Blood film + MCV + iron profile
C. Bone marrow biopsy
D. Platelet count

20. A child presents with pallor, fatigue, and normal MCV. Reticulocyte count is
elevated. Interpretation?

A. Bone marrow failure

B. Blood loss or hemolysis
C. Iron deficiency
D. Folate deficiency

✅ ANSWER KEY + EXPLANATIONS

1. B — Iron deficiency anemia

Microcytosis + pica + pallor = classic IDA.

Anemia by Mig

2. A — Hemophilia

Prolonged PTT with normal PT is hallmark.

HEMOPHILIA by Mig

3. B — Continue iron 3–4 months

Response takes weeks; treatment lasts months.

Anemia by Mig

4. A — Hemophilia

Bleeding after circumcision is typical early sign.

HEMOPHILIA by Mig

5. B — Packed RBC transfusion

Indicated for Hb <4 g/dL or heart failure.

Anemia by Mig

6. B — Polycythemia

High Hct + flushing + dizziness = classic.

Polycythemia by Mig

7. B — Secondary polycythemia
Triggered by hypoxia or low oxygen saturation.

Polycythemia by Mig

8. B — Increased RBC destruction

Hemolysis common in malaria.

Anemia by Mig

9. B — Hemarthrosis

Most common bleeding site in hemophilia.

HEMOPHILIA by Mig

10. B — Normal PT, prolonged PTT

Classic coagulation profile.

HEMOPHILIA by Mig

11. B — Delay iron until improved nutrition

Start iron after child begins eating & gaining weight.

Anemia by Mig

12. B — Phlebotomy

Immediate treatment to reduce blood viscosity.

Polycythemia by Mig

13. C — Treat hematuria

Steroids indicated for hematuria & hemarthrosis.

HEMOPHILIA by Mig

14. B — Iron deficiency anemia

Low iron + high TIBC is diagnostic.

Anemia by Mig
15. C — Stop transfusion immediately

First step in suspected transfusion reaction.

Anemia by Mig

16. B — Chronic synovitis

Recurrent hemarthrosis → joint damage.

HEMOPHILIA by Mig

17. B — Desmopressin

Increases factor VIII in mild hemophilia A.

HEMOPHILIA by Mig

18. A — Histamine release

Itching (aquagenic pruritus) typical of polycythemia.

Polycythemia by Mig

19. B — Blood film + MCV + iron profile

Essential for anemia classification.

Anemia by Mig

20. B — Blood loss or hemolysis

Elevated reticulocytes = marrow responding to RBC loss.

1. A 2-year-old with pallor, pica, and Hb 7 g/dL has low

MCV and high RDW. Most likely diagnosis?
A. Thalassemia
B. Iron deficiency anemia
C. Aplastic anemia
D. Hemolytic anemia
2. A child with iron deficiency anemia is started on ferrous
sulfate. Best dose?
A. 2 mg/kg/day
B. 6 mg/kg/day
C. 10 mg/kg/day
D. 12 mg/kg/day

3. A 7-year-old boy presents with painful swollen knee after

minor trauma. PTT prolonged; PT normal. Diagnosis?
A. ITP
B. Hemophilia A/B
C. DIC
D. Von Willebrand disease

4. A child with hemophilia A presents with hemarthrosis.

Best acute treatment?
A. DDAVP
B. Factor VIII concentrate
C. Fresh frozen plasma
D. Aspirin

5. A 6-year-old has headache, pruritus, facial flushing, and

Hct 60%. Most likely diagnosis?
A. Dehydration
B. Polycythemia vera
C. Leukemia
D. Anemia of chronic disease
6. A 14-year-old boy suddenly collapses during exercise.
ECG: delta wave, short PR. Condition?
A. WPW
B. HCM
C. MI
D. Pericarditis

7. A 5-year-old with fever, murmur, splinter hemorrhages,

and positive blood culture for S. viridans. Best treatment
duration?
A. 1 week IV
B. 4–6 weeks IV antibiotics
C. Oral antibiotics only
D. No therapy

8. A 3-year-old with 7 days of fever, conjunctivitis,

strawberry tongue, and rash. Best initial therapy?
A. IV antibiotics
B. IVIG + high-dose aspirin
C. Steroids
D. No treatment

9. A child with Kawasaki disease receives IVIG today. When

can live vaccines be given?
A. Next week
B. After 2 months
C. After ~11 months
D. Immediately
10. A 12-year-old with severe chest pain, troponin positive,
ST elevation in II, III, aVF. Diagnosis?
A. Anterior MI
B. Septal MI
C. Inferior STEMI
D. Pulmonary embolism

11. A child with nephrotic syndrome develops chest pain and

ECG consistent with MI. Most likely mechanism?
A. Coronary dissection
B. Hypercoagulability → thrombosis
C. Vasculitis
D. Hypotension

12. A 2-month-old preterm infant still requiring oxygen at 36

weeks PMA. Diagnosis?
A. RDS
B. Bronchopulmonary dysplasia
C. Asthma
D. CF

13. A preterm infant on mechanical ventilation develops

hyperinflation, atelectasis, and need for prolonged O₂.
Underlying mechanism?
A. Viral infection
B. Volutrauma + oxygen toxicity causing chronic lung disease
C. Excess surfactant
D. Immune deficiency
14. A school-aged child has recurrent wheezing triggered by
exercise and cold air. Most likely diagnosis?
A. Bronchiolitis
B. Pneumonia
C. Asthma
D. COPD

15. A 6-year-old has wheezing, tachypnea, and prolonged

expiration not improving with initial inhaled SABA.
Diagnosis?
A. Mild attack
B. Viral URI
C. Status asthmaticus
D. Bronchitis

16. A child with chronic cough, recurrent infections,

steatorrhea, and salty sweat. Most useful diagnostic test?
A. CXR
B. CBC
C. Sweat chloride test
D. Lung biopsy

17. A newborn fails to pass meconium → severe abdominal

distention → CF suspected. Cause?
A. Volvulus
B. Hirshsprung
C. Meconium ileus
D. NEC
18. A 1-year-old presents with persistent cough, failure to
thrive, and cervical lymphadenopathy. TB suspected. Most
supportive finding?
A. Tachycardia
B. Positive TST ≥10 mm
C. Negative CXR
D. Normal growth

19. A child with pulmonary TB has 3 negative sputum

smears but CXR shows hilar lymphadenopathy. Next step?
A. Stop evaluation
B. Treat as smear-negative TB
C. Steroids only
D. Repeat TST in a year

20. Best TB regimen in children (drug-sensitive)?

A. 6 months HR only
B. 2 months HRZE + 4 months HR
C. 9 months pyrazinamide
D. INH only

21. A 4-year-old with fever, tachycardia, hepatomegaly,

gallop rhythm. Likely diagnosis?
A. Pneumonia
B. Heart failure
C. Asthma
D. ARF
22. A newborn becomes cyanotic when crying but improves
when calm. CXR: boot-shaped heart. Condition?
A. TAPVR
B. Tetralogy of Fallot
C. VSD
D. ASD

23. A 7-year-old suddenly develops a systolic murmur and

migratory arthritis after sore throat 2 weeks ago. Likely
diagnosis?
A. Kawasaki
B. Acute rheumatic fever
C. JIA
D. Viral arthritis

24. A child with ARF has severe carditis. Best initial

management?
A. NSAIDs only
B. Corticosteroids + HF treatment
C. Antibiotics only
D. No therapy

25. A child with fever, weight loss, night sweats,

hepatosplenomegaly, pallor, and bone pain. Most likely
cancer?
A. Brain tumor
B. ALL
C. Hodgkin
D. Osteosarcoma
26. A teenager has mediastinal mass + cough + B symptoms.
Most likely?
A. Wilms tumor
B. Hodgkin lymphoma
C. Neuroblastoma
D. Ewing sarcoma

27. A 3-year-old has abdominal mass crossing midline, HTN,

and ↑ catecholamines. Diagnosis?
A. Wilms tumor
B. Neuroblastoma
C. Hepatoblastoma
D. HCC

28. A child with dilated cardiomyopathy has cool

extremities, HFrEF, pulmonary edema. Best acute
treatment?
A. Oral ACEI
B. IV inotropes (milrinone / dobutamine)
C. Steroids
D. NSAIDs

29. A child with infective endocarditis develops sudden

hemiparesis. Cause?
A. Abscess
B. Vasculitis
C. Septic emboli
D. Drug toxicity
30. A 9-year-old with congenital heart disease develops fever,
murmur, and Roth spots. Most likely organism?
A. S. pneumoniae
B. Viridans streptococci
C. S. epidermidis
D. H. influenzae

⭐ ANSWERS + EXPLANATIONS
1. B – Microcytic, high RDW → iron deficiency
2. B – Ferrous sulfate 6 mg/kg/day
3. B – Prolonged PTT, normal PT = hemophilia
4. B – Factor VIII replacement
5. B – Classic polycythemia vera signs
6. A – WPW pattern
7. B – IE requires 4–6 weeks IV antibiotics
8. B – IVIG + high-dose aspirin
9. C – Live vaccines delayed ~11 months after IVIG
10. C – Inferior wall MI
11. B – Hypercoagulable nephrotic syndrome
12. B – O₂ need at 36 weeks = BPD
13. B – Oxygen toxicity + ventilator injury
14. C – Classic asthma pattern
15. C – Status asthmaticus
16. C – Sweat chloride >60 mmol/L
17. C – Meconium ileus is classic CF
18. B – TST ≥10 mm = TB infection
19. B – Meets smear-negative TB criteria
20. B – HRZE × 2 months + HR × 4 months
21. B – HF signs: hepatomegaly, tachycardia
22. B – TOF → boot-shaped heart
23. B – ARF after strep infection
24. B – Severe carditis → steroids
25. B – ALL presents with pancytopenia + bone pain
26. B – Hodgkin = mediastinal mass + B symptoms
27. B – Neuroblastoma crosses midline
28. B – Shock/HF → IV inotropes
29. C – IE complication
30. B – S. viridans common in CHD IE